I have now been living in Singapore for approximately 19 months.
Singapore, for those who do not know about this Republic city-state, has
a population of about 5 million people. About 75% of these people are
Singapore Citizens or Permanent Residents--the rest are foreigners (like
myself). Singapore is a multi-cultural and multi-religious country. The
main ethnic groups are Chinese (about 75%) followed by Malayas and
Indians. Chinese, English, Malay and Tamil are the four official
languages of the nation. English is the 'official' language
and schools, universities and government and all teaching etc is
conducted in English. We have many holidays due to the multi-religious
aspect of the country so it is most enlightening for a Westerner such as
myself to learn about "Hungry Ghost" festivals and other such
interesting beliefs.

Singapore is 85 miles north of the Equator, and although they talk
about 'fall', 'spring' and 'winter' the
temperature is constant, hot and humid. It rains most days--lovely noisy
storms which cool down the temperature for a short while. Most newcomers
(and even older residents) have a slight sheen to them (hot and sweaty)!
Singapore is one of the most prosperous economies in the world. It is a
capitalist mixed economy with minimal government intervention. I call it
the 'city of cranes' as the amount of construction is amazing
and the speed is also unbelievable. Sitting in my office here at the
university looking out my window I can see 43 cranes! And this is only a
very small part of the island.

Singapore consists of one large island and about 59 small islands,
with most of the population on the main island. The main island is about
247 square miles, so it does not take long to drive from one end to the
other (except in peak hour or if there is a "jam"). It is
separated from Malaysia in the north and Indonesia in the south. There
are two 'crossing' land bridges to Malaysia. One has to get to
Indonesia by ferry. So everytime one gets on a plane it is an
international flight! And many Singaporean people drive or get buses
into Malaysia to do their shopping as the Singapore dollar is worth
about 2.5 times that of the Malaysian dollar. However, the crossings can
take quite some time, and so one has to learn to be patient!

Nothing is free in Singapore. There is no welfare and so people are
expected to work (the unemployment rate is 2.2%) and save for their
future. There is a compulsory savings scheme for health care and other
needs which Singaporeans contribute to while working. Thus for any
health care access there is a co-payment of some sort which can vary
depending upon the health insurance cover one has.

There is both a public and private medical and hospital system in
Singapore. However, one still pays in the public system (unlike
Australia which is free). About 20% of Singaporeans visit the government
primary care clinics (polyclinics) and about 80% go to one of the many
(and very large) public hospitals. There is no community or district
nursing as such. There is a beginning APN service, mostly in the
government hospitals and polyclinics. There are community hospitals (or
step-down) and long-term care facilities, although the latter are a
place of last resort as the culture is one of filial piety where the
eldest son or other member of the family are expected to care for
(physically and financially) the parents.

When I think of rural nursing and its primary health care focus and
the more autonomous role of the nurse, there is some transferability
within this highly urbanized environment. There are also gaps. Singapore
has a very poorly organized community or domicillary nursing service. It
used to have a visiting community nursing service in the past (I have
seen pictures of nurses wearing white uniforms and veils getting into
sampans to go across a river or to an island). However, home visiting
was stopped and people are now required to attend either the clinic or
the hospital. This, as one can image, can be difficult even on a small
island. While there is excellent public transport in Singapore (and it
is cheap), if one is disabled or sick, it is difficult to use this for
frequent access. Additionally, the taxi service can be quite expensive
if one is taking it every day. At this stage there are no programmes
such as 'hospital in the home' for patients who are discharged
early. There are some for profit and not-for-profit organizations that
provide home care, but these are means tested and are limited in their
availability.

In the polyclinics, however, there is an excellent self-management
model of chronic disease management which is nurse-led. Most of the
government polyclinics have been using this model for some time, where
an experienced registered nurse works as a case manager for a person
with chronic disease/s. Once the patient is diagnosed and stablised,
they are referred to the nurse who works as a case manager to provide
the education and lifestyle management needed. There is a co-payment for
this service. Very different from Australia, is the fact that prescribed
medications are given out at the polyclinic. Pharmacies (or drug stores)
do not dispense any drugs other than 'over-the-counter' or
Schedule 3 drugs. All prescription drugs are provided at the same time
as the visit to the doctor. This has good aspects (you don't have
to find a pharmacy to dispense the drug somewhere else) and bad points
(you can only get a couple of months at a time, which means you have to
go back more frequently, and then you have to store them in a fridge).
It is cheaper than Australia where we would pay through our subsidized
pharmacy system about $35 per medication and an out of pocket payment of
about $30 for the GP (much more for a specialist or for radiography).
Here in Singapore the doctor visit and medication cost me $5. It does
not prevent a person "doctor shopping" though as there is no
standard electronic health record in Singapore.

Very different to rural areas, there are many very large hospitals
here in Singapore. Not only are they large, but they are expanding their
bed numbers! For example, Singapore General Hospital (a tertiary
teaching hospital and the first and only Magnet Hospital in Asia) has
more than 30 specialty services and the 7,000 strong workforce annually
sees over 1 million patients. This is but one of the public hospitals in
Singapore. In addition to this large public hospital there are many
large private hospitals such as Raffles and Glen Eagles. Nurses in these
hospitals work similarly to nurses in acute care facilities other highly
developed countries.

So what is the future for Singapore? There is growing interest in
ways to deliver home care and home monitoring in a cost-effective way.
For example, there is interest in TeleHealth. One only has to be caught
in a "jam" for two hours to see how this technology would be
effective even in a highly urbanized environment. In fact anything high
tech would be seen to be great, as Singaporeans are among the first to
embrace any new technology. There is also recognition of the need to
grow community outreach services, and , in a society which is rapidly
ageing and in one where traditional cultural norms are being eroded,
there is a need for a new approach to aged and end of life care.

In many ways one sees that living in such an urban environment is
an advantage (no long distances to travel to obtain tertiary level
care). On the downside, however, from an Australian perspective, the
cost of services can be crippling and I would rather pay higher taxes as
I do in Australia and know that I can access health care without having
to sell my assets, than be in the situation in Singapore (which is
probably not unfamiliar to people living in the USA).

The status of nursing in Singapore is also very low. Nurses are not
paid well. Very different to Australia, most nurses in Singapore work
full-time (there is very little opportunity for part-time work). Most
are educated in one of the two Polytechnical Colleges and graduate with
a diploma. Or the enrolled nurses attend the Institute of Technical
Education. At NUS we only take about 90 students per annum into our
Bachelor of Nursing programme. Many of our nurses travel to Indonesia
and Malaysia to provide volunteer work and so see a very different type
of life--especially in the rural villages.

As you can imagine, many of the nurses are multi-lingual and speak
one or more Chinese dialects and Malay (or some Malay if they are
Chinese). This is needed to cope with the patients, especially those who
are older who do not speak English. The workforce is supplemented by
nurses from mainland China, the Phillipines, Malaysia, India and
Indonesia. These nurses make up some of the over 1 million foreign
workers in Singapore.

My research that I am undertaking here is a primary prevention
programme where we are screening a well population. I have two
registered nurses who are working with me and undertaking the screening.
We are supported by four cardiologists. So I have not moved away from
the primary health care focus that I developed in rural Australia!!!